#FridayImageChallenge (Friday comes early this week!)

#FridayImageChallenge

This week with all the excitement of the new intern class arriving – we are posting our #FridayImageChallenge early.

Another great case and this time 2 images – a CXR and CT. PJP

PJP2

Check back Monday for the answer and clinical pearls!

Credit: Spencer Carter

Send interesting ECGs/images to utswecg@gmail.com with short description of findings.

ANSWER: you were correct! PJP pneumonia

Imaging findings:
CXR R sided pneumothorax, bilateral diffuse interstitial infiltrates
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CT R sided pneumo s/p chest tube, diffuse ground glass opacities, cysts, peripheral inter and intralobular septal thickening

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History
A 38-year-old male presented to the emergency department with progressive dyspnea on exertion for one month and three hours of acute, severe shortness of breath. Social history was notable for unprotected sexual intercourse with males. Physical exam revealed diminished breath sounds on the right side. Chest X-ray was obtained showing right sided pneumothorax and bilateral infiltrates. A chest tube was placed emergently. Laboratory evaluation was notable for a CD4 count of <10 cells/mcL and HIV VL of 551,000 copies/mL. LDH and fungitell were elevated at 544 Units/L and 435 pg/mL respectively. CTA chest revealed diffuse bilateral ground glass opacities, cysts, and peripheral interlobular and intralobular septal thickening. He received three weeks of trimethoprim/sulfamethoxazole and glucocorticoids for PJP. His hospital course was complicated by a persistent bronchopulmonary fistula requiring five treatments of chemical pleurodesis. Four months later, he is doing well with a CD4 count of 246 cells/mcL on HAART.

PEARLS!

  • Epidemiology: Immunocompromised states highest risk (HIV with CD4 <200, transplant patients, long term high dose steroids, hematologic malignancies)
  • Presentation- non-HIV patients fulminant respiratory failure with fevers and dry cough for days-week. HIV patients often have more indolent course with weeks of symptoms (avg 3 weeks). Chest imaging with bilateral diffuse interstitial infiltrates, ground glass and cystic lesions often present on CT. ~5% cases complicated by pneumothorax
  • Treatment-First line therapy Bactrim (second line clinda/primaquine, TMP/dapsone, atovaquone only for mild cases). Concomitant treatment with glucocorticoids if Pao2 <70 or Aa gradient >35 (RR .56 at 1m compared to no steroids, NNT 9 w/o HAART, 23 with HAART). Patients can get worse 3-5 days after tx started, take into account when deciding on inpatient vs outpatient treatment
  • PJP ppx- HIV and CD4 <200, consider in solid organ transplant, stem cell transplant (at least 6m after engraftment, longer depending on immunosuppression), steroids >20mg daily for >1m, hematologic malignancies, primary immune deficiencies